Describing some of the most important disorders of the shoulder area: frozen shoulder, biceps tenosynovitis, biceps tendon tear, rotator cuff tear, impingement syndrome, Rotator Cuff Calcified Tendonitis

1. Disorders of the Shoulder
Farbod Zahedi Tajrishi
Medical student
Babol University of Medical Sciences

2. Preview
• Bones
• Joints
• Muscles
• Physical exam
• Tests and signs
• Diagnostic procedures

3. Bones of the Shoulder Area
• Humerus
• Clavicle
• Scapula

4. Joints of the Shoulder Area

5. Muscles of the Shoulder Area
A. The Rotator Cuff
 Supraspinatus
 Infraspinatus
 Subscapularis
 Teres minor
B. Big muscles
 Deltoid
 Pectoralis major
 Trapezius
 Latissimus dorsi
 Teres major
 Biceps

6. Physical exam
• Inspection: atrophy, bulging, deformity
• Palpation
• Range of motion: (active, passive / both sides)
- Forward elevation (abduction+flexion)(!)
- Adduction, int. rotation, flexion
- Abduction, ext. rotation, extension
• Tests and signs

7. Physical exam: Tests & signs
• Impingement sign  positive in rotator cuff
inflammation/ tearing
• Impingement test  injection of local anesthetic to
subacromial space. Positive if pain goes away.
• Apprehension sign  90 degrees abduction & ext.
rotation + mild pressure from behind. Positive in anterior shoulder
instability.
• Drop Arm sign  90 degrees abduction & mild int. rotation.
Positive if the patient can’t hold his/her arm without help.

8. Physical exam: Tests & signs

9. Diagnostic procedures: Radiography
• An AP view x-ray is enough in most cases.
• Lateral / Axillary view in specific cases, e.g.
posterior shoulder dislocation
• MRI / Arthrography for soft tissue injuries e.g.
rotator cuff tendon tearing

10. Diagnostic procedures: Arthroscopy
• Is used for dx. and tx. of most shoulder
disorders these days.

11. Biceps Tenosynovitis
• Usually affects biceps long head tendon
• Pain and inflammation after extensive exercise (e.g. tennis)
• Localized pain in bicipital groove
• Supination of the forearm increases the pain.
• Patients usually 30-40 y.o.
• Tx:
- rest, heating the painful area, NSAID,
- local hydrocortisone

12. Biceps Tendon Tear
• Etiology: sudden contraction e.g. heavy load
• Clinical presentation:
- 50-60 y.o. / upper or lower portion (usually upper)
- sudden & extreme pain which decreases over a short period
of time is a characteristic sign
- flexion and ext. rotation weakening of the forearm
- arm deformity (oval shape turns to round & its site changes)
- tenderness in tearing site
- ecchymosis in tearing site
- ROM of the shoulder is NORMAL

13. Biceps Tendon Tear
• Treatment:
A) older patients  surgery NOT necessary
B) younger patients  surgery

14. Degenerative Arthritis of Shoulder
• Etiology: hx. of past trauma to shoulder & tearing of
the rotator cuff muscles
• Clinical presentation: usually > 50 y.o. / shoulder
restriction of movement / pain with rotational
movements
• Dx: radiography ed articular space, sclerosis,
osteophyte
• Tx:
-medical: NSAID, physiotherapy, Intra-articular steroid
-surgical: joint replacement

15. Frozen Shoulder
 Definition:
Shoulder restriction of movement to all sides
due to fibrosis in articular capsule

16. Frozen Shoulder
• Etiology:
1) Primary ( idiopathic )
2) Secondary : trauma to / surgery on shoulder
- Underlying causes such as diseases of the heart,
brain & neck, breast cancer and diabetes 
articular capsule fibrosis due to stimulation of
neurologic reflexes
- Psychological
** decreased articular space in both forms

17. Frozen Shoulder
• Clinical presentation:
- Mostly female / 5th & 6th decades
- Three clinical phases:
1. Persistent pain (esp. at night) + total limitation of movement
2. ed pain (or no change) + ed limitation of movement
3. Movements gradually return to normal form
- int. rotation is the first affected motion in frozen shoulder
- Limitation of passive movements (esp. rotation) to all sides is the key to dx
- Arthrography confirms the dx  obvious decreased articular volume

18. Frozen Shoulder
• Treatment:
- Depends on the stage of the disease
- Patient education in all phases
- Corticosteroid / long acting local anesthetic inj.
- Manipulation of shoulder under anesthesia (stage
2,3)  increases range of motion
- Arthroscopy (releases fibrotic capsule)
- Surgery (rarely)

19. Frozen Shoulder
• Psychotherapy is suggested due to the
psychological underlying causes of the disease
• Long-term prognosis is good.
• 80% of ROM returns in most cases

20. Rotator Cuff Tear
• Muscles and their functions:
1. Supraspinatus: humerus stabilizer + arm abduction
2. infraspinatus: ext. rotation
3. Teres minor
4. Subscapularis: int. rotation

21. Rotator Cuff Tear
• Anatomy:
Origin: scapula
Insertion:
subscapularis  lesser tuberosity of humerus
others  greater tuberosity of humerus

22. Rotator Cuff Tear
• Etiology
1. Rotator cuff tendons chronically get stuck
between acromion process & greater
tuberosity
2. trauma

23. Rotator Cuff Tear
• Clinical presentation:
- Shoulder pain (the most imp.):
1. anterior with radiation to the arm
2. Mild at first and only when elevating the arm
3. Progression: pain at rest, frozen shoulder
- Decreased ROM (esp. start of shoulder abd.)
- In complete rotator cuff tear & supraspinatus tendon tear, the patient can’t start
shoulder abduction, however, if the shoulder is passively abducted (30 degrees) then
he/she can continue the abduction by using deltoid muscle.

24. Rotator Cuff Tear
• Physical exam:
1. Jobe test (empty can)
2. Ext. rotation stress test
3. Lift-off test

25. Rotator Cuff Tear
MRI is the best choice for diagnosis

26. Rotator Cuff Tear
• Treatment:
1. Non-surgical: (50% useful)
- decreasing over-head activities of the shoulder
- NSAID
- corticosteroid inj.
- physiotherapy
2. Surgical
IMPORTANT: Complete rest leads to frozen shoulder so it is not
indicated in tx. of rotator cuff tear.

27. Rotator Cuff Tear
• Indications for surgical treatment:
1. No response to non-surgical tx.
2. Massive tearing
3. Acute tear (caused by trauma) esp. in young patients
4. Active patients esp. tear in dominant shoulder
5. Tear + muscular weakness

28. Impingement Syndrome
• Etiology:
- daily over head over activity & sports such as
tennis and swimming (Swimmer’s Shoulder)
- rotator cuff tendons esp. supraspinatus
tendon get stuck between humerus and
acromion process.
- acromion deformity

29. Impingement Syndrome
• Clinical presentation:
- Usually >40 y.o / starts gradually but trauma
or exercise can trigger an acute onset
- Low to moderate pain while active
- Empty can sign (pain and limited motion with
forward elevation & internal rotation) (imp.)
- Painful arc syndrome (pain with 45 to 120
degrees abd.)

30. Impingement Syndrome
- Sometimes: trauma -> broad tendon tear ->
inability to move shoulder -> drop arm test +
- Hawkins-Kennedy sign +
- Neer (Impingement) Sign +

31. Impingement Syndrome
• Diagnosis:
- No sign in AP radiograph
- Spur on the anterior border of
acromion/acromial deformity in true lateral x-
ray view of scapula
- Arthrography & MRI to rule out rotator cuff
tendon tear

32. Impingement Syndrome
• Treatment:
- heavy activities
- Physiotherapy
- NSAID
- Long acting corticosteroid (methyl prednisolone
inj.) in sub-acromial bursa (repeated injections
increases the risk of tendon degeneration & tear)
- Surgery (open or arthroscopy) if no response
after 3-6 months of treatment (esp. in case of
acromion deformity

33. Rotator Cuff Calcified Tendonitis
• Definition
• Epidemiology :
- 20 to 25 y.o / caucasian / male / western
countries
• Three phases
1. Calcium formation in tendon -> pain
2. Stability -> mild, chronic pain
3. Absorption -> scar & granulation tissue replaces
calcium , inflammation, throbbing pain

34. Rotator Cuff Calcified Tendonitis
• Radiographic finding: accumulation of calcium
under acromion process
• Treatment:
- Stage 1,2 : NSAID + physiotherapy
- Stage 3 : steroid + Saline inj. To subacromial space
/ ice pack / morphine for severe pain
- Arthroscopic surgery in case of no response
• Prognosis: calcium will be absorbed finally and
the pain goes away

35. Thank you for your
attention
Farbod Zahedi Tajrishi, Nov. 2015